| 中文摘要 |
中央健康保險署107下半年度擬全面導入住院診斷關聯群（Taiwan Diagnosis Related Groups, Tw-DRGs）4.0版支付通則及未實施項目。Tw-DRGs支付制度以住院病患的診斷、手術條件，分成不同的群組，是一種同病同酬的支付制度。同一疾病診斷為腰椎滑脫症（lumbar spondylolisthesis, ICD-10-CM為M43.16），醫院採用新術式以非融合手術施行之DRG項目代碼為49901-50002，健保給付DRG定額5萬多；另以傳統脊椎融合術之DRG項目代碼為49701-49804，健保給付DRG定額約計10萬。脊椎融合術與非融合手術目的相同，由於使用的手術方法不同，所耗健保醫療資源有很大的差異，且4.0版Tw-DRGs針對脊椎融合術在DRG定額給付外，另增加核實申報脊椎固定特材項目。一個腰椎問題的兩種手術方法，在健保給付上的倍數差異，對於實施內容仍有疑慮，支付政策可能影響醫療行為，考量Tw-DRGs實施屬重大支付制度變革，徵詢專科醫學會意見，在導入支付政策的方向及內容、醫師的手術方式選擇與病人選擇的治療方式，審慎評估全面導入Tw-DRGs的發展，共創三贏。
The National Health Insurance Administration (NHI) is planning to fully introduce the General Rules for Taiwan Diagnosis Related Groups (Tw-DRGs) Payment Policy Version 4.0 with the addendum of suspended items in the second half of 2018. The Tw-DRGs Payment Policy is an “equal compensation for the same disease＂ policy, dividing in-patients into different groups based on the diagnoses and surgical conditions. Take the disease diagnosis “lumbar spondylolisthesis＂ (ICD-10- CM: M43.16) as an example, the DRG code is 49901-50002 and the NHI payment is approximately NT 50,000 if the hospital decides to perform the novel approach (non-fusion surgery). However, if the hospital performs traditional spine fusion, the NHI payment is approximately NT 100,000 (DRG code: 49701-49804). Although the final outcomes between the two approaches are the same, the NHI payments are significantly different. Moreover, for spine fusion, Tw-DRGs Version 4.0 pays for additional spine fusion materials in addition to the original DRG payment. Given that the NHI payments (for the same lumbar problem) between these two surgical approaches are markedly distinct, which may lead to different medical behavior, it is required to introduce a thorough review system for the Tw-DRGs payment policy. The Tw-DRGs policy shall be in line with the development of novel technology. Health Insurance, doctor and patient, become win-win situation. |
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